complaint·January 22, 2026

It was alleged that R1’s responsible party is emotionally abusing R1 at the facility by encouraging them to eat when they’re not hungry, telling them in a “threatening tone” that they will not be able to go on outings if they don’t eat, and encouraging R1 to walk when they’re tired. Per a statement from R1’s hospice company, R1’s hospice nurse assessed R1 on April 14, 2021, R1 denied any concerns of emotional abuse by their responsible party, R1 stated they felt “relaxed” in the presence of their responsible party, R1 reported that their responsible party encourages them to eat to “get stronger” but does not force feed them, R1 also denied being forced to walk when too tired and reported that their responsible party encourages them to walk but takes them back to their room when they’re ready, and facility staff denied observing concerns for emotional abuse by R1’s responsible party. LPA reviewed R1’s Physician’s Report dated March 1, 2021, which indicates R1 does not have dementia. LPA interviewed AAD who stated that R1’s responsible party has been good and diligent with R1, comes to see R1 on a daily basis, is very emotionally close with R1, does not yell at R1, and treats R1 well. Per AAD, facility staff have never seen R1’s responsible party do anything bad with R1 and R1 really likes their responsible party. LPA interviewed R1 who denied the allegation, stating their responsible party treats them well and they have no concerns at the facility. LPA interviewed two additional residents who raised no safety concerns at the facility. LPA interviewed R1’s responsible party who denied the allegation and raised no concerns about the facility. No information was obtained corroborating the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. LPA reviewed R1’s hospice medical records which confirmed that R1’s rash was being assessed and treated by R1’s hospice care team. LPA interviewed AAD who stated that R1 has a history of rashes, R1 recently had a rash that got better after an anti-fungal cream was used, and facility staff regularly provide R1 showers, check on R1, and ensure R1’s incontinence needs are met. LPA reviewed R1’s Physician’s Report dated March 1, 2021, which confirms that R1 has a history of rashes. LPA interviewed R1 who denied the allegation, stating facility staff noticed and obtained treatment for their rash quickly and they have no concerns at the facility. LPA interviewed two additional residents who raised no care concerns at the facility. LPA interviewed R1’s responsible party who denied the allegation, stating the rash was properly addressed, and raised no care concerns at the facility. In addition to the rash, one witness reported that R1’s incontinence needs are not being met, there were issues with R1’s medications, and R1 had a urinary tract infection that was not addressed properly. Regarding R1’s incontinence care, R1 and R1’s responsible party did not corroborate any issues with incontinence care, with R1’s responsible party confirming that R1 was checked on and changed regularly. However, both the witness and R1’s responsible party confirmed that R1’s diapers, even if changed timely, leaked due to being the wrong size. LPA interviewed AAD who stated that R1’s diapers were provided by hospice and if they were the wrong size, then R1’s hospice bath aide, R1’s responsible party who came every day to see R1, or the facility’s staff would have noticed, raised the issue with hospice, and the diaper size would have been changed. LPA reviewed R1’s hospice medical records which confirmed R1’s diapers were provided by hospice. The information obtained did not corroborate that the facility failed to address the diaper size issue, including because the issue started with hospice and R1 and their responsible party could have addressed the issue directly with hospice. Regarding R1’s medications, the witness reported that the facility was giving R1 antacids with medications that could not be combined with antacids. LPA interviewed AAD who was unable to provide information regarding this issue. LPA reviewed R1’s hospice medical records which list R1’s medications during the relevant time period and noted R1 was prescribed milk of magnesia, but there is no special instruction that any medications on R1’s medication list cannot be taken together. Regarding R1’s urinary tract infection, LPA interviewed AAD who could not identify whether R1 had any specific urinary tract infections, but stated that residents like R1 who receive incontinence care are at higher risk for urinary tract infections, staff check for signs and symptoms during changes, and any concerns are reported to the resident’s doctor. LPA reviewed R1’s Physician’s Report dated March 1, 2021, and hospice medical records and did not note any documentation regarding urinary tract infections. When interviewed, R1 and their responsible party raised no concerns regarding urinary tract infections. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.